Pharmacy Providers

ND Medicaid Rebate Program Guide for Labelers

Mailing/Physical Address: 

North Dakota Health and Human Services
Attn: Fiscal – Drug Rebate Program 
600 E. Blvd. Ave., Dept 325 
Bismarck, ND 58505-0261 

Contact Information:

• Questions on usernames and passwords for ND’s RebateWeb and for dispute issues – rebatewebnd@nd.gov
• For invoice and payment questions – ndrebates@nd.gov 

Please note, payments can only be for one program per check. ROSIs and PQASs must be mailed/emailed to ndrebates@nd.gov with each payment. 

We now (April 2021) accept payments through EFT/ACH. Please send an email to ndrebates@nd.gov – subject line: ACH Payment Process to receive instructions regarding setting up your company. 

To view/download CLD or invoices, please visit our ND RebateWeb site (state specific). Invoices are mailed and delivered electronically if labeler requested electronic through the ND RebateWeb site. 

*New program starting 1q22. ND Medicaid Expansion FFS Medical (EXPFFSJ & EXPFFSJSU). Currently just 19-20 year old Expansion members (carved out of MCO).

Managed Care

For physician administered drug claims for Medicaid expansion, 340B product billing is not allowed.

Groups IDs that are Invoiced for Rebates Herein Referenced as "ND Programs"

NDMEDIATTBRP, NDMEDICHPFFS, NDMEDIEMERSA, NDMEDIEPSDT, NDMEDIEXPMCO, NDMEDIFFS, NDMEDIHOSPCE, NDMEDICCM, NDMEDIRSSLVR, NDMEDIRYNWHT

Billing Instructions:

These require apply whenever ND Programs are a payer on the claim, whether as a primary, secondary, tertiary payer, etc. Please see our payer sheet for BIN, PCN, Group numbers.

Out of State, Nursing Home, In-house and Specialty Pharmacies

All information in this 340B section applies to all providers including out of state, nursing home, in-house, and specialty pharmacies.

Covered Entities

Covered entities are defined in section 1927 (a)(5)(B) of the Social Security Act. Covered entities must indicate they wish to be 340B providers in their provider enrollment paperwork. Only those providers who have enrolled as 340B providers will be allowed to bill for 340B products.

Fee-For-Service

For pharmacy and physician administered drug claims for traditional Medicaid and pharmacy drug claims for Medicaid expansion, 340B product billing is allowed for those enrolled with ND Medicaid and identified in their enrollment as 340B providers.

However, ND Medicaid pays a calculated ceiling price, and most providers choose to not use 340B supply.

Contract Pharmacies

Contract pharmacies are not allowed to bill for 340B product and must carve out ND Programs unless the contract pharmacy is only considered a contract pharmacy due to the ND pharmacy ownership law and an agreement has been reached between the provider and ND Medicaid.

Federally Qualified Health Centers

Federally Qualified Health Centers (FQHCs) are paid an encounter rate, so their claims are not eligible for rebates. FQHCs may use 340B supply if they wish.

Excluded Products:

Some products are required to be excluded from 340B billing. Excluded NDCs for 340B

Pharmacy Dispensed Drugs

Drugs billed to ND Programs with a NCPCP submission clarification code of 20 are excluded from the drug rebate invoicing process to avoid duplicate discounts. ND Medicaid does not pay secondary on Medicare Part D claims.

When billing 340B product to ND Programs where the 340B discount is given as an upfront discount for prescriptions, covered entities are required to bill: 

• No more than their actual acquisition cost plus the professional dispensing fee
• An NCPDP submission clarification code of 20 when using 340B product

When billing 340B product to ND Programs where the upfront cost does not include the 340B discount but is later provided as a rebate to the provider for prescriptions, covered entities are required to bill: 

• No more than the 340B ceiling price plus the professional dispensing fee
• An NCPDP submission clarification code of 20 when using 340B product

Physician Administered Drugs

Drugs billed to ND Programs on a claim line with a TB or UD modifier are excluded from the drug rebate invoicing process to avoid duplicate discounts.

When billing 340B product to ND Programs where the 340B discount is given as an upfront discount for prescriptions, covered entities are required to bill: 

• No more than their actual acquisition
• A TB or UD modifier on the claim line for the drug when using 340B product

When billing 340B product to ND Programs where the upfront cost does not include the 340B discount but is later provided as a rebate to the provider for prescriptions, covered entities are required to bill: 

• No more than the 340B ceiling price
• A TB or UD modifier on the claim line for the drug when using 340B product

HRSA Medicaid Exclusion File

Since providers must identify as 340B providers in their enrollment, and since our 340B claims are identified using modifiers during claim submission, we do not use the HRSA Medicaid Exclusion File.

Drugs Included in Medicare Dialysis Bundled Payment

We do not invoice for drugs included in the Medicare dialysis bundled payment when those claims crossover to ND Medicaid. If ND Medicaid is the primary payer for dialysis, drugs are paid separately and we do invoice for those drugs if they do not have a 340B modifier. If they do have a 340B modifier, covered entities are required to bill per the pharmacy dispensed drugs or physician administered drugs instructions above.

ND Medicaid covers products by default as they appear in the First DataBank database files that are loaded weekly into our system. Please use the NDC Drug Lookup tool which is also populated by the First DataBank drug database files for coverage and reimbursement information.  

New Labeler: When a labeler newly enters into a National Drug Rebate Agreement (NDRA) to participate in the Medicaid Drug Rebate Program (MDRP), our system will be updated with the next quarterly CMS file. Coverage will begin by the mandatory coverage date.

Drugs that cost over $3,000 for a month's supply: Drugs be covered according to the package insert. If it is part of an already existing PDL category, it’ll be added to that category. An update will be provided to the DUR board the following meeting in the PDL update. General utilization management measures, such as quantity limits, therapeutic duplication, and diagnosis requirements will be implemented as applicable.

Oncology Medications: Oncology medications will simply be covered with a quantity limit and to FDA and compendia diagnoses, with no step therapy. Clinical presentations are generally not necessary, due to the lack of impact on management.

Clinical Presentations: The best timing for a clinical presentation to the ND team is shortly after FDA approval or launch. The ND team applies utilization management and strategizes for PDL placement and criteria after drugs are launched so the presentation is highly relevant during this time and is less likely to have the important clinical information lost in the shuffle.

• Please fill out the Pharmacy Industry Meeting Application on the DUR Board vendor's website and email to medicaidpharmacy@nd.gov or fax to (701) 328-1544.
• Things we find especially informative during presentations:
  • Place in therapy
  • Highlighting the differences between your drug and the current drugs in the marketplace
  • Unique mechanisms of action and how the mechanism affects the disease state vs other drugs on the market
  • Relevant clinical guidelines
  • Real world data
  • Distribution plans
• Clinical presentations are generally not needed for classes that are not managed. Most commonly these would be oncology medications. North Dakota will always reach out for more information when needed so a simple greeting and informative drug launch email to medicaidrx@nd.gov is often the best strategy for oncology medications.

Reimbursement: ND Medicaid uses the methodology of lesser of NADAC or MAC if NADAC is available, or lesser of WAC and MAC if NADAC is not available. Please use the NDC Drug Lookup tool to lookup reimbursement information.

DUR Board Review:

• Agenda: The DUR Board Agenda will be posted on the DUR Board vendor’s website 30 days prior to the meeting. Chemotherapy, HIV/AIDs, antidepressants, antipsychotics, seizure, and immunosuppressants for prophylaxis of organ transplant rejection classes are currently excluded from prior authorization so will not be reviewed for prior authorization or step therapy criteria at the DUR meeting.
• Public Comment: Please email Julie McKee at julie.mckee@acentra.com and provide any materials to be distributed to the board members. This is not a requirement to be allowed to speak at the DUR Meeting but is appreciated for an orderly meeting and record keeping. Public comments must be related to agenda item. Public comments will be allowed for first and second reviews and annual prior authorization reviews. For more information regarding public comments, please see the ND Medicaid DUR Board Procedures
• Annual Prior Authorization Review: The annual review for all classes subject to prior authorization occurs in the December meeting.

Supplemental Rebates: ND Medicaid participates in the Sovereign States Drug Consortium (SSDC) supplemental rebate pool. Please visit the SSDC website to view information on the consortium and how to submit a rebate offer. ND Medicaid has been approved by CMS to participate in value-based agreements as a state. Please contact medicaidrx@nd.gov or SSDC if you are interested in pursuing a value based agreement.